Cardiovascular System

A $72$-year-old man visits the urgent care clinic complaining of progressive difficulty breathing and a non-productive cough over the past $3$ days. He states his "asthma" is acting up again and requests a refill of his inhalers. His past medical history includes severe chronic obstructive pulmonary disease (COPD) requiring $2$ L/min of home oxygen, ischemic heart disease with a prior myocardial infarction, and type $2$ diabetes mellitus. His current medications include inhaled tiotropium, inhaled fluticasone-salmeterol, and metformin. Vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $162/94$ mm Hg, heart rate of $115$/min, and respiratory rate of $26$/min. Oxygen saturation is $89\%$ on his baseline $2$ L/min oxygen. The patient is sitting upright and using accessory muscles to breathe. Examination of the neck demonstrates distended external jugular veins up to the angle of the mandible while sitting at a $45^\circ$ incline. Lung auscultation reveals diffuse expiratory wheezing and scattered fine crackles at the bilateral lung bases. Cardiac examination reveals a regular tachycardia with a low-frequency diastolic sound heard just after S2 at the cardiac apex. Abdominal exam reveals mild hepatomegaly. Bilateral pitting edema is noted up to the mid-calves. Bedside ultrasound of the lungs demonstrates diffuse, vertically oriented, laser-like artifacts extending from the pleural line to the bottom of the screen (B-lines) in all lung fields. Which of the following is the most appropriate initial pharmacological intervention for this patient's current condition?

Match each distinct electrocardiographic (ECG) finding with its most characteristic underlying structural or anatomical pathology.

A 72-year-old man visits the outpatient clinic reporting a four-week history of progressively worsening shortness of breath and a persistent, dry cough. His medical history includes coronary artery disease, ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, paroxysmal atrial fibrillation, and mild chronic obstructive pulmonary disease. He smoked cigarettes for 30 years but quit a decade ago. Current medications include lisinopril, metoprolol succinate, spironolactone, apixaban, and an antiarrhythmic agent initiated six months ago to maintain normal sinus rhythm. Vital signs show a blood pressure of 128/78 mm Hg, a pulse of 68/min, and a respiratory rate of 20/min. Pulse oximetry is 91% on room air. Jugular venous pressure is normal at 6 cm $H_2O$. Lung auscultation reveals bilateral fine, "Velcro-like" inspiratory crackles, but no wheezing or rhonchi. Cardiac examination shows a regular rate and rhythm with no murmurs or gallops. There is no lower extremity edema. A high-resolution computed tomography scan of the chest demonstrates bilateral ground-glass opacities and reticular interstitial thickening. Which of the following is the most appropriate next step in the management of this patient?

A 73-year-old retired accountant is evaluated in the emergency department for severe, progressively worsening breathlessness over the past 48 hours. The patient has a 45-pack-year smoking history, essential hypertension, and hyperlipidemia. He reports needing to sleep propped up on three pillows to avoid suffocating and describes a non-productive cough. Temperature is $37.0^\circ \text{C}$, blood pressure is $172/98 \text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $26/\text{min}$. Pulse oximetry shows $88\%$ on room air. The patient is sitting on the edge of the bed, using accessory muscles to breathe. Jugular venous pressure is measured at $11 \text{ cm H}_2\text{O}$. Lung auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezes and scattered crackles at the lung bases. Cardiac examination shows a laterally displaced apical impulse and an early diastolic sound heard best at the apex. Bilateral $1+$ pitting edema is present in the lower extremities. Arterial blood gas on room air shows a pH of 7.30, PaCO2 of $55 \text{ mmHg}$, PaO2 of $58 \text{ mmHg}$, and HCO3 of $26 \text{ mEq/L}$. Chest radiograph demonstrates cephalization of the pulmonary vasculature, peribronchial cuffing, and a small right-sided pleural effusion without focal consolidation. Which of the following is the most appropriate initial pharmacological intervention for this patient's presentation?

Match each patient's clinical presentation with its most likely characteristic cardiovascular pathology.

Match each cardiovascular medication used in the management of arrhythmias and other cardiac conditions with its most characteristic adverse effect profile.

A 71-year-old man is transported to the hospital by emergency medical services due to the abrupt onset of severe difficulty breathing. Three days ago, the patient experienced a prolonged episode of substernal discomfort and diaphoresis but declined to seek medical care, assuming it was severe heartburn. His medical history includes hypertension, hyperlipidemia, and a 45-pack-year history of smoking.

On arrival, his blood pressure is 88/54 mm Hg, heart rate is 118/min, and respiratory rate is 26/min. Oxygen saturation is 86% on room air. The patient is diaphoretic and unable to speak in full sentences. Neck veins are distended. Lung auscultation reveals diffuse bilateral crackles and prominent expiratory wheezing. Cardiac examination demonstrates a rapid regular rhythm with a loud, blowing holosystolic murmur that is most prominent at the cardiac apex and radiates to the left axilla.

An electrocardiogram displays normal sinus rhythm with prominent Q waves and inverted T waves in leads II, III, and aVF.

Based on the clinical presentation, which of the following is the most likely etiology of this patient's acute respiratory distress?

During a routine workplace health screening, an occupational physician evaluates a veteran mechanic who has been struggling to walk across the garage floor without stopping to catch his breath over the past month. The patient reports waking up multiple times at night feeling suffocated, a sensation that improves after sitting on the edge of his bed for several minutes. He has smoked a pack of cigarettes daily for thirty years. Blood pressure is 142/88 mm Hg, heart rate is 98/min, and respiratory rate is 20/min. Physical examination reveals an apical impulse palpated in the sixth intercostal space, anterior to the midaxillary line. Auscultation identifies an extra low-frequency heart sound occurring just after S2. Lung auscultation demonstrates fine inspiratory crackles in the dependent zones bilaterally without wheezing or prolonged expiration. Which of the following is the most appropriate initial diagnostic test to establish the underlying cause of this patient's symptoms?

A 64-year-old woman with a known history of severe emphysema presents to her primary care physician due to progressive swelling in both her legs over the past three weeks. She notes a mild increase in exertional fatigue but denies any recent fever, chills, chest pain, or changes in her baseline chronic daily cough. Her temperature is 37.0°C (98.6°F), blood pressure is 128/78 mmHg, pulse is 96/min, and respiratory rate is 18/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals a barrel-shaped chest and distant heart sounds. A prominent right ventricular heave is palpated along the left sternal border. When the patient is positioned at 45 degrees, her jugular venous pulsations are visible 6 cm above the sternal angle. Lung auscultation demonstrates globally diminished breath sounds with a prolonged expiratory phase, but no crackles or wheezes are heard. There is 2+ pitting edema in both lower extremities extending to the mid-calves. Which of the following is the most likely underlying pathophysiological mechanism responsible for this patient's new physical examination findings?

A 55-year-old hospitalized man collapses while walking in the telemetry unit hallway. He is unresponsive, and no carotid pulse is palpable. A code blue is activated, and high-quality cardiopulmonary resuscitation (CPR) is initiated. The defibrillator pads are applied, and the monitor displays coarse ventricular fibrillation.

Arrange the following critical management steps in the chronological order they should be performed according to advanced cardiovascular life support (ACLS) protocols, assuming the patient remains in refractory ventricular fibrillation throughout the resuscitation.

A $72$-year-old man comes to the clinic reporting a $6$-week history of progressively worsening shortness of breath, a dry cough, and generalized fatigue. He has a history of paroxysmal atrial fibrillation and a myocardial infarction $3$ years ago. His daily medications include apixaban, amiodarone, metoprolol succinate, and atorvastatin. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $128/78\text{ mm Hg}$, and pulse of $64\text{/min}$. Oxygen saturation is $92\%$ on room air. Jugular venous pressure is $6\text{ cm H}_2\text{O}$. Cardiac auscultation reveals a regular rate and rhythm with no murmurs, rubs, or gallops. Pulmonary examination reveals fine bilateral inspiratory crackles but no wheezing. Laboratory studies reveal:

- Leukocyte count: $7,200/\text{mm}^3$
- Brain natriuretic peptide (BNP): $85\text{ pg/mL}$ (normal $< 100\text{ pg/mL}$)
- Thyroid-stimulating hormone (TSH): $7.2\text{ }\mu\text{U/mL}$ (normal: $0.4\text{--}4.0\text{ }\mu\text{U/mL}$)
- Free $T_4$: $1.8\text{ ng/dL}$ (normal: $0.9\text{--}1.7\text{ ng/dL}$)

High-resolution computed tomography of the chest demonstrates bilateral ground-glass opacities and focal areas of consolidation. Which of the following is the most appropriate next step in management?

A 64-year-old woman is brought to the emergency department by emergency medical services due to severe, worsening shortness of breath that began 24 hours ago. The patient has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (GOLD stage III). Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $170/95\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $86\%$ on room air. She appears in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation reveals prolonged expiration, diffuse expiratory wheezing, and bilateral crackles at the lung bases. Cardiovascular examination shows distant heart sounds, a normal S1 and S2, and a prominent S3 gallop. The jugular venous pressure is estimated at $13\text{ cm H}_2\text{O}$. There is $2+$ bilateral lower extremity pitting edema.

Laboratory studies show:

Chest radiograph reveals cardiomegaly, bilateral pleural effusions, and cephalization of the pulmonary vasculature. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with its corresponding primary structural or hemodynamic finding.

During physical examination of the cardiovascular system, palpation of the arterial pulse can provide critical clues regarding underlying hemodynamics. Match the following characteristic arterial pulse abnormalities with the cardiovascular condition they most classically represent.

A 59-year-old woman suddenly collapses while walking in the hospital corridor. A rapid response team arrives immediately. The patient is completely unresponsive, apneic, and has no palpable carotid pulse. The team brings a crash cart with a manual defibrillator, and cardiac monitoring reveals coarse ventricular fibrillation. Arrange the following resuscitative interventions in the correct chronological sequence according to current Advanced Cardiac Life Support (ACLS) guidelines for this rhythm.

A 62-year-old man with a history of ischemic cardiomyopathy suddenly collapses while walking in the hospital corridor. A rapid response team arrives immediately. The patient is unresponsive, apneic, and has no palpable carotid pulse. High-quality chest compressions are initiated, and a defibrillator is attached. The monitor displays coarse ventricular fibrillation.

Assuming the patient remains in refractory ventricular fibrillation throughout the resuscitation, arrange the following advanced cardiac life support (ACLS) interventions in the correct chronological sequence.

Match each characteristic arterial pulse finding on physical examination with its most likely underlying cardiovascular pathology.

Match the following cardiac arrhythmias and conduction disorders with their characteristic electrocardiogram (ECG) findings.

A 65-year-old man is brought to the emergency department due to severe, sudden-onset shortness of breath that awakened him from sleep. The patient has a history of essential hypertension, hyperlipidemia, type 2 diabetes mellitus, and a 35-pack-year history of smoking. Current medications include amlodipine, metformin, and atorvastatin.

Temperature is 37.1°C (98.8°F), blood pressure is 210/115 mmHg, heart rate is 115/min, and respiratory rate is 28/min. Pulse oximetry is 88% on room air.

Physical examination reveals an anxious, diaphoretic man in severe respiratory distress, utilizing accessory muscles of respiration. Lung auscultation reveals a prolonged expiratory phase with diffuse bilateral wheezing and scattered crackles in the lower lung fields. Cardiac examination shows a tachycardic, regular rhythm with a prominent S4 gallop and no murmurs. There is 1+ bilateral pitting edema of the lower extremities.

Chest radiograph demonstrates bilateral perihilar alveolar opacities, indistinct pulmonary vascular margins, and cephalization of the pulmonary veins. There is no focal lobar consolidation.

Which of the following is the most appropriate initial step in the management of this patient?

A $71$-year-old woman is evaluated in the surgical step-down unit for a sudden onset of shortness of breath and a nonproductive cough. She is currently on postoperative day $3$ following an uncomplicated right total knee arthroplasty. Her medical history is significant for coronary artery disease, heart failure with preserved ejection fraction, and a $40$-pack-year smoking history with known chronic obstructive pulmonary disease. Her temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $168/96\text{ mmHg}$, pulse is $108/\text{min}$, and respirations are $26/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination reveals distended neck veins with a jugular venous pressure of $11\text{ cm H}_2\text{O}$. Chest auscultation demonstrates a prolonged expiratory phase with diffuse bilateral wheezes and scattered bibasilar crackles. Cardiac examination reveals a regular tachycardia with a distinct S4 gallop and no murmurs. Her lower extremities show bilateral $2+$ pitting edema, which is unchanged from her preoperative baseline. Which of the following is the most appropriate next step in management?